Does Your Oncologist Care?

Facing advanced cancer, who among us wouldn’t look to our oncologist for expert advice on whether another round of chemotherapy makes sense?  But do you know what your oncologist cares about, and can you be sure her recommendations map onto your own treatment preferences?

A recent study lead by Michael Kozminski (I was senior author) shows that American oncologists downplay the value of treatments that improve quality of life, compared to the value they place on life prolonging treatments.

In our study, we surveyed oncologists across the United States and presented them with hypothetical treatment scenarios, to see what value they placed on potential treatments for patients with advanced cancer.

In one scenario, we estimated how cost-effective a new life prolonging chemotherapy would need to be before oncologists prescribed it.  We described the chemotherapy as prolonging patients’ lives, but also explained that we had no other data on how it impacted quality of life.  On average, we found that oncologists would be willing to spend as much as $200,000 for every year of life gained by this new treatment.

In another scenario, we described a new chemotherapy that provided the same length of life as existing treatments, but that also substantially improved patients’ quality of life: “improving it from 40 to 90 on a 0-to-100 scale.”  According to standard theories of health economics, each year of life after receiving this treatment brings a half of a quality adjusted life year, or QALY.  When contemplating this life improving drug, however, oncologists weren’t willing to spend as generously.  Maybe $1000,000 for a QALY, but nowhere near the $200,000 they would spend for a QALY produced by a life-prolonging drug.

In cancer treatment, patients and doctors are often faced with the difficult job of balancing the desire for quantity versus quality of life.  Some treatments prolong life but at a major cost to quality of life, with miserable side effects, days and weeks spent in the hospital beds in oncology clinics rather than home with family and friends.  Every patient needs to decide what balance to strike between quantity and quality of life.  In doing so, most patients rely on advice from their oncologists.

Should they rely on this advice?

Medical recommendations often depend on non-medical judgments.  If your oncologist cares primarily about how long you live, and downplays the importance of your quality of life, she might recommend a treatment that doesn’t match your own values.

When getting any kind of medical advice, remember that the right decision often depends as much on your values as on the medical facts at hand.  Don’t seek or accept advice from a physician until you feel they, at a minimum, understand your values, such as how much you care about quantity versus quality of life.

If you ever face an illness forcing you to decide between living long or prospering, make sure it is your values that rule the day, not your doctor’s.

Peter Ubel is a physician, behavioral scientist and author of Pricing Life: Why It’s Time for Health Care Rationing and Free Market Madness. He teaches business and public policy at Duke University. Peter’s new book, Critical Decisions will be available in the fall of 2012. You can follow him on his personal blog.

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4 replies »

  1. Frankly, I’ve heard a lot of stories about this issue and seen a lot of economic evidence that supports what you’re saying, but I think the issue is more complicated than this post lets on. (In fairness, your post is an overview of your study results, not a full report.) I think oncologists by definition are going to go with the conventional wisdom in the field, which is currently “we do what we can, when we can – but we’re increasingly stopping and asking hard questions.”

    Worth noting, many doctors, facing the same set of awful choices when their own care is concerned, choose not to prolong care and opt out.

    See the earlier THCB post “How Doctors Die” for a good example:

  2. What a nice post! I’m deeply moved by your ideas regarding quantity and quality of life. I’ve realized that we, as patients, have the right to choose and decide about health management and treatment.

  3. Have seen this dilemma play out a couple of ways. My dad, faced with another surgery and another recovery, at 75, felt he didn’t have it in him, opted for radiology to treat a cancerous lung tumor. Of course, the surgeon advocated for surgery, the radiologist advocated for radiology, neither asked him his goals and values. So 18 months later, after diminishing quality of life, on death bed, wondered if he should have gone with the surgery. Who’s to say whether that would have extended life.

    My friend with recurrent, metastasized cancer, treated aggressively at first, got about 18 more good months. But nothing would change the outcome, so she skipped further chemo and ensuing misery and sought comfort care instead. Her care team was in utter confusion at her choice. Good thing she wasn’t easily swayed or she’d have spent final months being sicker from chemo than cancer.

  4. Medical technology has done much to extend our lifespans, but has created all kinds of dilemmas for the patient. What to do or not to do? And on top of that, in the U.S., can I afford it? What if I don’t follow the recommendations of my doctor? Guilt? Shorter life? Miserable end of life? Sometimes I think we would be better letting things take their course and dealing with our mortality head on.

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